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For Providers and Staff

Please note that the Johns Hopkins Community Health Partnership (J-CHiP) is no longer accepting patients and has transitioned beyond the award. Johns Hopkins remains committed to leveraging the important work and learnings of J-CHiP across the delivery system through future programs to improve care coordination.

What is the Partnership’s Goal?

A group of providers sits around a table to discuss patient casesMultidisciplinary inpatient rounds at The Johns Hopkins Hospital

The Johns Hopkins Community Health Partnership (J-CHiP) aims to advance the quality and efficiency of care by encouraging community members, especially those who have been patients at The Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center or neighboring ambulatory clinics, to optimize their health behaviors and be accountable for the choices that affect their health.

The program seeks to improve care and accountability for the total cost of care for both care teams and patients. It also includes a robust set of standards for quality and patient experience that allow for cost savings.

Catalyzed by a $19.9 million, three-year grant from the Centers for Medicare & Medicaid Services (CMS), the focus of the partnership is on underserved and high-risk adult patients receiving care in East Baltimore, especially those with chronic illness, substance abuse or mental illness and patients discharged from The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center.

By July 2015, nearly all adult patients discharged from The Johns Hopkins Hospital and Johns Hopkins Bayview will receive some services through the Partnership, translating to tens of thousands of patients per year.

Through care teams consisting of physicians, case workers, nurses, pharmacists and other clinical or nonclinical staff, the program ensures that discharged patients have what they need to follow the treatment plans drawn up by their Johns Hopkins physicians and to stay healthy and out of the hospital.

You can download a flier that contains information for Johns Hopkins Medicine staff and a flier for patients.

How Will It Help Health Care Providers?

Primarily, the program offers improved communication and coordination among providers and care teams, leading to more efficient and effective care. Primary care physicians also benefit from innovative IT solutions and a workforce prepared to support them and the patients enrolled in the program. Patients will learn self-care management and receive home-based services. Students and trainees will be educated on the science of health care delivery. It will create value for our patients, our providers and our community.

How Does the Program Work?

The goal is to reduce preventable hospital admissions and unnecessary emergency department visits and testing through improved community-based care management, more effective inpatient and discharge processes and highly coordinated care.

Critical components include:

  • Inpatient care coordination for adults admitted to The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center that includes interventions to improve outcomes and reduce readmission risk, including:
    • Early risk screening
    • Multidisciplinary care planning
    • Enhanced medication management
    • Patient and family education
    • Provider communication
    • Integration of behavioral health services into all components of care
    • Post-discharge support when transitioning back to the community
  • Primary care coordination for patients who come to Johns Hopkins Medicine clinics and a Baltimore Medical System clinic (Highlandtown) within or near seven identified zip codes surrounding The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center.
  • Care for patients of The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center who are discharged to five neighboring skilled nursing facilities. Through collaborative efforts, strategies are developed and implemented to promote effective care transitions and clinical care management.
  • Partnership with two community-based organizations, Sisters Together and Reaching and the Men and Families Center, to address the challenges facing the health of the East Baltimore Community.

To learn more about the Johns Hopkins Community Health Partnership, take this 15 minute e-learning course for an introductory overview: The Business of JHHC | Johns Hopkins Community Health Partnership. A JHED log-in is required.